Displacement of Double Lumen Tube After the Rupture of a Giant Lung Bulla During Bullectomy

Abstract

To the Editor: Malpositioning of a double lumen tube (DLT) can occur during airway management for intrathoracic procedures.1 We encountered an unusual cause of right sided DLT displacement in a 23-yr-old patient scheduled for elective left side bullectomy. Computed tomography scan of the chest (Figure 1) revealed a giant bulla occupying left apical, lingular, and part of the lower lobe with significant mediastinal shift towards the right. After induction of anesthesia and tracheal intubation, the patient was positioned for left postero-lateral thoracotomy with two-lung ventilation initially. During dissection, the bulla was suddenly punctured and deflated. The relief from compressive effects of the bulla did not improve lung mechanics. There was no lung expansion on left side and a paradoxical increase in peak airway pressure, followed by arterial hemoglobin desaturation, increased end tidal carbon dioxide, and an absence of breath sounds over right apical region. Fiberoptic bronchoscopy revealed a distally displaced DLT in the right bronchus (Figure 2). Withdrawing the tube gradually restored audible breath sound on the right apical region and completely resolved the problem. We conclude that, following rupture of the bulla, a leftward carinal shift over a relatively fixed DLT led to placement of the DLT more distally inside the right bronchus.Figure 1.: CT Chest showing a giant bulla with tracheal shift.Figure 2.: Schematic illustration of carinal shift over relatively fixed of DLT.In conclusion, while identifying the causes of arterial desaturation during DLT ventilation, the possibility of a misplaced DLT due to intraoperative carinal shift after rupture of a giant bulla must also be considered. Deepak Thapa, DA, DNB Lakshmi Mahajan, MD Lalit Gupat, DA Department of Anaesthesia and Intensive Care Government Medical College and Hospital Chandigarh, India [email protected]